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Exfoliation Treatment Consent 

 

 

I have read the below information and initialed each section to indicate that I fully understand what to expect. If I have any questions or concerns, I will address these with my esthetician and HBC. I give permission to my Esthetician, Brittni with HBC, to perform the exfoliation treatment we have discussed and will hold her and her staff harmless from any liability that may result from this treatment. I understand she will take every precaution to minimize or eliminate negative reactions such as blisters, sores, or other reactions, as much as possible. I do understand that, very rarely, permanent damage occurs. I have given an accurate account of any over the counter or prescription medications that I use regularly, and I am not presently using (nor have I used within the last year) isotretinoin (Accutane), Retin-A, Acyclovir or tranquilizers. I have not had any facial surgical procedures, piercings, tattoos, permanent cosmetics, or other chemical peels or skin treatments that I have not disclosed to my esthetician. I am not ingesting or using topically any other over the counter product or prescription medication/agent that has not been disclosed to my therapist. I am not presently pregnant or lactating and I am over the age of eighteen (18). I have not had any recent radioactive or chemotherapy treatments, sunburn, windburn or broken skin. I have not recently waxed or used a depilatory (such as Nair) on the area to be treated. I do not have a history of keloidal scarring, diabetes, any auto immune disease, active herpes blisters, or any other existing condition that may interfere with the positive outcome of this treatment.

I understand that I should not have a exfoliation peel if I intend to continue to have excessive sun exposure. It has been explained to me that the treated area will be more sensitive to the sun as a result of the treatment and will require regular use of sunscreen​

I consent to the taking of photographs to monitor treatment effects, as desired or recommended by my esthetician.

 

My expectations are realistic and I understand that the results are not guaranteed and that for maximum results, more than one application may be required. The rate of improvement of my skin depends on my age, skin type and condition, degree of sun/environmental damage, pigmentation levels, or acne condition. ​

I understand that this procedure is expected to make the skin feel uncomfortable while being applied, but agree to inform the skin professional immediately if I have concerns or am overly uncomfortable during treatment or after I return home.

I agree that I am willing to follow recommendations by my therapist for home care. I will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of adhering to a sunscreen and avoiding the sun/tanning booths and extreme weather conditions. I agree to use a moisturizer specifically recommended by my esthetician and I acknowledge that I have been informed of the possible negative reactions (intense erythema, welts, scabs) and the expected sequence of the healing process (dryness, irritation, redness, and peeling of the skin). In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult my esthetician immediately​.

I understand the potential risks and complications and have chosen to proceed with the treatment after careful consideration of the possibility of both known and unknown risks, complications, and limitations. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. ​

 

 

First Client Name

First Name*

Middle Name

Last Name*

Phone*
First Client Date of Birth*
First Client Signature*
Second Client Name

First Name*

Middle Name

Last Name*

Phone*
Second Client Date of Birth*
Third Client Name

First Name*

Middle Name

Last Name*

Phone*
Third Client Date of Birth*
Fourth Client Name

First Name*

Middle Name

Last Name*

Phone*
Fourth Client Date of Birth*
Fifth Client Name

First Name*

Middle Name

Last Name*

Phone*
Fifth Client Date of Birth*
Sixth Client Name

First Name*

Middle Name

Last Name*

Phone*
Sixth Client Date of Birth*
Seventh Client Name

First Name*

Middle Name

Last Name*

Phone*
Seventh Client Date of Birth*
Eighth Client Name

First Name*

Middle Name

Last Name*

Phone*
Eighth Client Date of Birth*
Ninth Client Name

First Name*

Middle Name

Last Name*

Phone*
Ninth Client Date of Birth*
Tenth Client Name

First Name*

Middle Name

Last Name*

Phone*
Tenth Client Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Please list any medications.

Please list any used within the last 30 days. Or if Accutane within the last year.
Please list any conditions currently being treated by a medical professional.

IE Diabetes, HIV, Chemo, Radiation etc
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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